Search

International audience; BackgroundThe optimal dose of tranexamic acid to inhibit hyperfibrinolysis in postpartum haemorrhage is unclear. Tranexamic Acid to Reduce Blood Loss in Hemorrhagic Cesarean Delivery (TRACES) was a double-blind, placebo-controlled, randomised, multicentre dose-ranging study to determine the dose–effect relationship for two regimens of intravenous tranexamic acid vs placebo.MethodsWomen experiencing postpartum haemorrhage during Caesarean delivery were randomised to receive placebo (n=60), tranexamic acid 0.5 g (n=57), or tranexamic acid 1 g i.v. (n=58). Biomarkers of fibrinolytic activation were assayed at five time points, with inhibition of hyperfibrinolysis defined as reductions in the increase over baseline in D-dimer and plasmin–antiplasmin levels and in the plasmin peak time.ResultsIn the placebo group, hyperfibrinolysis was evidenced by a mean increase over baseline [95% confidence interval] of 93% [68–118] for D-dimer level at 120 min and 56% [25–87] for the plasmin–antiplasmin level at 30 min. A dose of tranexamic acid 1 g was associated with smaller increases over baseline (D-dimers: 38% [13–63] [P=0.003 vs placebo]; plasmin–antiplasmin: –2% [–32 to 28] [P=0.009 vs placebo]). A dose of tranexamic acid 0.5 g was less potent, with non-significant reductions (D-dimers: 58% [32–84] [P=0.06 vs placebo]; plasmin–antiplasmin: 13% [18–43] [P=0.051]). Although both tranexamic acid doses reduced the plasmin peak, reduction in plasmin peak time was significant only for the 1 g dose of tranexamic acid.ConclusionsFibrinolytic activation was significantly inhibited by a dose of intravenous tranexamic acid 1 g but not 0.5 g. Pharmacokinetic–pharmacodynamic modelling of these data might identify the best pharmacodynamic monitoring criteria and the optimal tranexamic acid dosing regimen for treatment of postpartum haemorrhage.

Background Pregnant women are at increased risk of hypoxaemia during general anaesthesia. Our aim was to determine the incidence and the risk factors that contribute to hypoxaemia in this setting. Methods Every woman 18 yr or older who underwent a non-elective Caesarean section under general anaesthesia was eligible to participate in this multicentre observational study. The primary endpoint was the incidence of hypoxaemia defined as the SpO2 ≤95%. The secondary endpoint was the incidence of difficult intubation defined as more than two attempts or failed intubation. Results During the study period, 895 women were prospectively included in 17 maternity hospitals, accounting for 79% of women who had general anaesthesia for non-elective Caesarean section. Maternal hypoxaemia was observed in 172 women (19%; confidence interval [CI], 17–22%). Risk factors associated with hypoxaemia in the multivariate analysis were difficult or failed intubation (adjusted odds ratio [aOR]=19.1 [8.6–42.7], P 35 kg m−2 (aOR=0.53 [0.28–0.998], P=0.0495). Intubation was difficult in 40 women (4.5%; CI, 3.3–6%) and failed intubation occurred in five women (0.56%; CI, 0.1–1%). In the multivariate analysis, use of a hypnotic drug other than propofol was associated with difficult or failed intubation (aOR=25 [2–391], P=0.02). A propensity score confirmed that propofol was associated with a significant decreased risk of difficulty or failure to intubate (P Conclusions Hypoxaemia during Caesarean sections was observed in 19% of women and was significantly associated with difficult or failed intubation. The use of propofol may protect against the occurrence of difficult intubation.

ImportanceInformation about the severity of Omicron is scarce.ObjectiveTo report the respective risk of ICU admission in patients hospitalized with Delta and Omicron variants and to compare the characteristics and disease severity of critically ill patients infected with both variants according to vaccination status.DesignAnalysis from the APHP database, called Reality, prospectively recording the following information in consecutive patients admitted in the ICU for COVID-19: age, sex, immunosuppression, vaccination, pneumonia, need for invasive mechanical ventilation, time between symptom onset and ICU admission, and in-ICU mortality. Retrospective analysis on an administrative database, “Système d’Information pour le Suivi des Victimes” (SI-VIC), which lists hospitalized COVID-19 patients.Setting39 hospitals in the Paris area from APHP group.ParticipantsPatients hospitalized from December 1, 2021 to January 18, 2022 for COVID-19.Main outcomes and measuresRisk of ICU admission was evaluated in 3761 patients and Omicron cases were compared to Delta cases in the ICU in 888 consecutive patients.ResultsOn January 18, 45% of patients in the ICU and 63.8% of patients in conventional hospital units were infected with the Omicron variant (p < 0.001). The risk of ICU admission with Omicron was reduced by 64% than with Delta (9.3% versus 25.8% of cases, respectively, p < 0.001). In critically ill patients, 400 had the Delta variant, 229 the Omicron variant, 98 had an uninformative variant screening test and 161 did not have information on variant screening test. 747 patients (84.1%) were admitted for pneumonia. Compared to patients infected with Delta, Omicron patients were more vaccinated (pConclusion and relevanceCompared to the Delta variant, the Omicron variant is less likely to result in ICU admission and less likely to be associated with pneumonia. However, when patients with the Omicron variant are admitted for pneumonia, the severity seems similar to that of patients with the Delta variant, with more immunocompromised and vaccinated patients and no difference in adjusted in-ICU mortality. Further studies are needed to confirm our results.

International audience; No abstract available

Objective To define for women at low obstetric risk methods of management that respect the rhythm and the spontaneous course of giving birth as well as each woman's preferences. Methods These clinical practice guidelines were developed through professional consensus based on an analysis of the literature and of the French and international guidelines available on this topic. Results Labor should be monitored with a partograph (professional consensus). Digital cervical examination should be offered every 4 h during the first stage of labor, hourly during the second. The choice between continuous (cardiotocography) or discontinuous (by cardiotocography or intermittent auscultation) monitoring should be left to the woman (professional consensus). In the active phase of the first stage of labor, dilation speed is considered abnormal if it is less than 1 cm/4 h between 5 and 7 cm or less than 1 cm/2 h after 7 cm. In those cases, an amniotomy is recommended if the membranes are intact, and the administration of oxytocin if the membranes are already broken and uterine contractions are judged insufficient (professional consensus). It is recommended that pushing not begin when full dilation has been reached; rather, the fetus should be allowed to descend (grade A). Umbilical cord clamping should be delayed beyond the first 30 s in newborns who do not require resuscitation (grade C). Conclusion The establishment of these clinical practice guidelines should enable women at low obstetric risk to receive better care in conditions of optimal safety while supporting physiologic birth.

Thromboembolic events may occur both during and after pregnancy Pregnancy in itself increases the thromboembolic risk, which is even greater during the postpartum period Due to additional coagulation changes induced by COVID-19 infection, this risk may even be greater

International audience; Anaphylaxis is a systemic acute hypersensitivity reaction that is considered to depend on allergen-specific immunoglobulin E (IgE) antibodies and histamine release by mast cells and basophils. Nevertheless, allergen-specific IgG antibodies have been proposed to contribute when the allergen is an abundant circulating large molecule, e.g., after infusions of therapeutic antibodies or dextran. Data from animal models demonstrate a pathway involving platelet-activating factor (PAF) release by monocytes/macrophages and neutrophils activated via their Fc gamma receptors (FcγRs). We hypothesized that such a pathway may also apply to small drugs and could be responsible for non-IgE-mediated anaphylaxis and influence anaphylaxis severity in humans. We prospectively conducted a multicentric study of 86 patients with suspected anaphylaxis to neuromuscular-blocking agents (NMBAs) during general anesthesia and 86 matched controls. We found that concentrations of anti-NMBA IgG and markers of FcγR activation, PAF release, and neutrophil activation correlated with anaphylaxis severity. Neutrophils underwent degranulation and NETosis early after anaphylaxis onset, and plasma-purified anti-NMBA IgG triggered neutrophil activation ex vivo in the presence of NMBA. Neutrophil activation could also be observed in patients lacking evidence of classical IgE-dependent anaphylaxis. This study supports the existence of an IgG-neutrophil pathway in human NMBA-induced anaphylaxis, which may aggravate anaphylaxis in combination with the IgE pathway or underlie anaphylaxis in the absence of specific IgE. These results reconcile clinical and experimental data on the role of antibody classes in anaphylaxis and could inform diagnostic approaches to NMBA-induced acute hypersensitivity reactions.

Postpartum haemorrhage (PPH) is defined as blood loss >= 500 mL after a delivery and severe PPH as blood loss >= 1000 mL, regardless of the a route of delivery (professional consensus). The preventive a administration of uterotonic agents just after delivery is effective in a reducing the incidence of PPH and its systematic use is recommended, a regardless of the route of delivery (Grade A). Oxytocin is the first a line prophylactic drug, regardless of the route of delivery (Grade A); a a slowly dose of 5 or 10 IU can be administered (Grade A) either IV or IM a (professional consensus).After vaginal delivery, routine cord drainage a (Grade B), controlled cord traction (Grade A), uterine massage (Grade a A), and routine bladder voiding (professional consensus) are not a systematically recommended for PPH prevention. After caesarean delivery, a placental delivery by controlled cord traction is recommended (grade B). a The routine use of a collector bag to assess postpartum blood loss at a vaginal delivery is not systematically recommended (Grade B), since the a incidence of severe PPH is not affected by this intervention. In cases a of overt PPH after vaginal delivery, placement of a blood collection bag a is recommended (professional consensus). The initial treatment of PPH a consists in a manual uterine examination, together with antibiotic a prophylaxis, careful visual assessment of the lower genital tract, a a uterine massage, and the administration of 5-10 IU oxytocin injected a slowly IV or IM, followed by a maintenance infusion not to exceed a a cumulative dose of 40 IU (professional consensus). If oxytocin fails to a control the bleeding, the administration of sulprostone is recommended a within 30 minutes of the PPH diagnosis (Grade C). Intrauterine balloon a tamponade can be performed if sulprostone fails and before recourse to a either surgery or interventional radiology (professional consensus). a Fluid resuscitation is recommended for PPH persistent after first line a uterotonics, or if clinical signs of severity (Grade B). The objective a of RBC transfusion is to maintain a haemoglobin concentration (Hb) >8 a g/dL. During active haemorrhaging, it is desirable to maintain a a fibrinogen level >= 2 g/L (professional consensus). RBC, fibrinogen and a fresh frozen plasma (FFP) may be administered without awaiting a laboratory results (professional consensus). Tranexamic acid may be used a at a dose of 1 g, renewable once if ineffective the first time in the a treatment of PPH when bleeding persists after sulprostone administration a (professional consensus), even though its clinical value has not yet a been demonstrated in obstetric settings. It is recommended to prevent a and treat hypothermia in women with PPH by warming infusion solutions a and blood products and by active skin warming (Grade C). Oxygen a administration is recommended in women with severe PPH (professional a consensus). If PPH is not controlled by pharmacological treatments and a possibly intra-uterine balloon, invasive treatments by arterial a embolization or surgery are recommended (Grade C). No technique for a conservative surgery is favoured over any other (professional a consensus). Hospital-to-hospital transfer of a woman with a PPH for a embolization is possible once hemoperitoneum is ruled out and if the a patient's hemodynamic condition so allows (professional consensus). (C) a 2015 Elsevier Ireland Ltd. All rights reserved.

Objective Neuraxial morphine is considered as a "gold standard" for pain relief after cesarean section, however it causes bothersome side effects. Alternative analgesia including nonsteroidal antiinflammatory drugs (NSAID) has been proposed. We aimed to assess the morphine sparing effect of continuous wound infiltration with a local anesthetic, when added to multimodal systemic analgesia including NSAID without subarachnoid morphine. Study design Sixty-eight women scheduled for elective cesarean section under spinal anesthesia were included in a randomized controlled open-label trial. Patients received bupivacaine spinal anesthesia without intrathecal morphine. Postoperative analgesia consisted for all patients in multimodal systemic analgesia with acetaminophen, nefopam, celecoxib, and patient-controlled intravenous morphine for 24h. The intervention group also received subfascial levobupivacaine infiltration through a multi-holed catheter, at 6.25mg/h for 48h. The primary endpoint was total morphine consumption at 24h postoperatively; and secondary endpoints were pain scores, side effects, breastfeeding comfort, maternal satisfaction, and nurse workload. Student t test, Mann–Whitney test or χ 2 test were used when appropriate. Results The intervention group had 6.7mg less morphine consumption (95%CI −1.3mg; −12mg, P =0.02), and 0.8 pain point less at rest on the numerical rating scale 0–10 (95%CI −0.3; −1.3, P =0.002). The intervention was associated with significantly better breastfeeding comfort (+1.7 at numerical rating scale score 0–10, 95%CI +0; +3.3, P =0.0498). Wound dressing changes were required in a significantly higher proportion of intervention-group women (12/34 vs. 1/34, P =0.002). Conclusion Adding continuous levobupivacaine infiltration to multimodal analgesia after cesarean section without subarachnoid morphine decreased postoperative morphine consumption and pain, facilitated breastfeeding initial comfort, and slightly increased nurse workload.

Resume Le nombre d’anesthesies realisees chez des femmes ayant une grossesse meconnue est estime entre 0,15 % et 2,2 % de l’ensemble des interventions effectuees chez les femmes en âge de procreer. Une chirurgie realisee chez une femme enceinte est potentiellement a risque de complications maternelles et/ou embryofœtales. Il est donc important en cas de depistage d’une grossesse meconnue, d’avoir la possibilite de discuter des risques avec une patiente informee et d’adapter les techniques chirurgicales et anesthesiques le cas echeant. S’il est etabli que les agents anesthesiques utilises aux concentrations cliniques et dans le respect de la physiologie maternelle ne sont pas teratogenes, les risques de fausses couche ou d’accouchements prematures sont augmentes par la chirurgie et l’anesthesie en cours de grossesse. De fait, de nombreuses societes savantes y compris la Societe francaise d’anesthesie et de reanimation (Sfar) preconisent aujourd’hui un depistage systematique de la grossesse chez les femmes en âge de procreer avant tout acte necessitant une anesthesie. Ce depistage s’appuie dans un premier temps sur un interrogatoire cible afin de preciser l’eventualite d’une grossesse. S’il existe un doute, le recours a un dosage plasmatique de la sous-unite β de l’hormone chorionique gonadotrope (test de sensibilite et de specificite de 100 %) apres consentement de la patiente, est recommande. En cas de confirmation de la grossesse, et en fonction de la balance du benefice/risque maternofœtal, le report de l’intervention doit etre envisage chaque fois que possible.

International audience; Postpartum haemorrhage (PPH) is defined as blood loss ≥500mL after delivery and severe PPH as blood loss ≥1000mL, regardless of the route of delivery (professional consensus). The preventive administration of uterotonic agents just after delivery is effective in reducing the incidence of PPH and its systematic use is recommended, regardless of the route of delivery (Grade A). Oxytocin is the first-line prophylactic drug, regardless of the route of delivery (Grade A); a slowly dose of 5 or 10 IU can be administered (Grade A) either IV or IM (professional consensus). After vaginal delivery, routine cord drainage (Grade B), controlled cord traction (Grade A), uterine massage (Grade A), and routine bladder voiding (professional consensus) are not systematically recommended for PPH prevention. After caesarean delivery, placental delivery by controlled cord traction is recommended (grade B). The routine use of a collector bag to assess postpartum blood loss at vaginal delivery is not systematically recommended (Grade B), since the incidence of severe PPH is not affected by this intervention. In cases of overt PPH after vaginal delivery, placement of a blood collection bag is recommended (professional consensus). The initial treatment of PPH consists in a manual uterine examination, together with antibiotic prophylaxis, careful visual assessment of the lower genital tract, a uterine massage, and the administration of 5-10 IU oxytocin injected slowly IV or IM, followed by a maintenance infusion not to exceed a cumulative dose of 40IU (professional consensus). If oxytocin fails to control the bleeding, the administration of sulprostone is recommended within 30minutes of the PPH diagnosis (Grade C). Intrauterine balloon tamponade can be performed if sulprostone fails and before recourse to either surgery or interventional radiology (professional consensus). Fluid resuscitation is recommended for PPH persistent after first line uterotonics, or if clinical signs of severity (Grade B). The objective of RBC transfusion is to maintain a haemoglobin concentration (Hb) >8g/dL. During active haemorrhaging, it is desirable to maintain a fibrinogen level ≥2g/L (professional consensus). RBC, fibrinogen and fresh frozen plasma (FFP) may be administered without awaiting laboratory results (professional consensus). Tranexamic acid may be used at a dose of 1 g, renewable once if ineffective the first time in the treatment of PPH when bleeding persists after sulprostone administration (professional consensus), even though its clinical value has not yet been demonstrated in obstetric settings. It is recommended to prevent and treat hypothermia in women with PPH by warming infusion solutions and blood products and by active skin warming (Grade C). Oxygen administration is recommended in women with severe PPH (professional consensus). If PPH is not controlled by pharmacological treatments and possibly intra-uterine balloon, invasive treatments by arterial embolization or surgery are recommended (Grade C). No technique for conservative surgery is favoured over any other (professional consensus). Hospital-to-hospital transfer of a woman with a PPH for embolization is possible once hemoperitoneum is ruled out and if the patient's hemodynamic condition so allows (professional consensus).

Resume Le jeune altere le confort des parturientes en cours de travail. De plus en plus de centres, notamment en Europe, proposent de poursuivre l’ingestion de liquides durant le travail. Cette attitude ne semble pas modifier l’incidence des inhalations bronchiques qui reste extremement faible. Il ne semble pas que l’apport de liquides retarde la vidange gastrique au cours du travail. Le jeune augmente la neoglucogenese chez la parturiente et la production de corps cetoniques egalement chez le fœtus. Les apports glucidiques per os n’ont, par ailleurs, aucun impact sur le deroulement du travail. La plupart des societes savantes recommandent donc le maintien des ingestions de liquides au cours du travail obstetrical en evitant les ingestions d’aliments solides.

International audience; BACKGROUND: To determine the efficacy and safety of intravenous postoperative morphine titration in the elderly compared with younger patients. METHODS: In the post-anaesthesia care unit, patients complaining of pain received morphine until adequate pain relief. Intravenous morphine was titrated as 3 mg boluses in young (age 65 yr) and 2 mg in elderly patients (>65 yr) every 5 min. RESULTS: We studied 350 young and 68 elderly patients. There were no significant differences between the two age groups for pain intensity at the onset of titration (numerical rating scale, 7.4 +/- 1.7 in young vs. 7.5 +/- 1.7 in elderly patients), area under the curve of numerical rating scale vs. morphine boluses (97.7 +/- 59.6 vs. 98.2 +/- 62), number of boluses required to obtain pain relief (3 +/- 1.3 vs. 3 +/- 1.3), percentage of titration failures (10% vs. 9%) and incidence of excessive sedation (18% vs. 21%). Renal clearance was significantly reduced in elderly compared with young patients (55 +/- 21 vs. 85 +/- 15 mL min(-1); P < 0.0001). CONCLUSION: Using lower bolus doses, pain relief in the immediate postoperative period with morphine was as efficacious and safe in elderly patients as in younger patients. The decrease in renal clearance of morphine in the elderly justifies the reduction of intravenous morphine boluses for the treatment of postoperative pain.

Reference values for rotation thromboelastometry (ROTEM®) parameters following non-haemorrhagic deliveries. Correlations with standard haemostasis parameters

Use of morphine by titration in the post-anaesthesia care unit (PACU) is often the first step in postoperative pain management. This approach provides rapid analgesia but shows a wide inter-individual variability in morphine requirements and may prolong patient stay in the PACU. The aim of this study was to identify the patient characteristics, surgical, anaesthetic, and postoperative factors predictive of early morphine requirements. The study included 149 patients undergoing various non-cardiac surgical procedures under general anaesthesia. In the multiple regression analysis of nine variables, only ethnicity (Caucasian), emergency surgery, major surgery, surgery exceeding 100 min, and pain score on arrival in PACU were predictive factors of morphine requirements. This observational study identifies for the first time independent predictive factors of morphine requirements in the early postoperative period. Future studies are warranted to evaluate the impact of intervention on these factors and any resulting improvement in postoperative pain treatment.

Since increased tyrosine phosphorylation has been observed in response to brain ischemia, we investigated whether riluzole (an inhibitor of glutamate neurotransmission with neuroprotective properties) affects tyrosine phosphorylation stimulated by N -methyl- d -aspartate (NMDA) in rat hippocampal slices. Riluzole produced an extremely potent concentration-related inhibition of NMDA (1 mM)-stimulated protein tyrosine phosphorylation (IC 50 =0.5±0.03 μM, mean±S.D.), but failed to affect that evoked by phorbol 12-myristate 13-acetate (PMA, an activator of protein kinase C, 0.1 and 1 μM). These results suggest that inhibition of tyrosine phosphorylation may contribute to the neuroprotective effects of riluzole against excitotoxic injury.

Introduction Hors contexte obstetricale, il a ete demontre que l’echelle visuelle analogique (EVA) et l’echelle numerique (EN) etaient correlees mais que cette correlation etait plus forte pour les scores de douleur bas par rapport aux scores plus eleves [1] . Il a egalement ete decrit une difference entre ces 2 echelles dans leur capacite a detecter un soulagement de la douleur apres traitement [1] . Nous avons mene une etude sur la douleur obstetricale pour determiner la correlation et le degre d’agrement entre l’EVA et l’EN, ainsi que la sensibilite de ces 2 echelles a detecter un soulagement apres l’APD. Patientes et methodes Etude prospective observationnelle menee sur une periode d’un mois dans une maternite de type 3. Les patientes en travail desireuses d’une APD ont ete incluses. Avant et 30 min apres la pose de l’APD, les parturientes ont eu une evaluation par EVA et EN au pic des contractions uterines. De plus, 30 min apres l’APD, elles indiquaient leur niveau de soulagement en donnant le % de reduction de la douleur. Pour l’EVA et l’EN, le % de reduction de la douleur etait calcule : 100 × ([score avant APD − score apres APD]/score avant APD). Les donnees demographiques et obstetricales ont ete recueillies. Analyse statistique par coefficient de concordance de correlation (CCC) et graphique de Bland et Altman avec limites d’agrement (1,96 × ecart-type [ET]). Resultats Trente et un patientes ont ete incluses. Leurs caracteristiques figurent dans le Tableau 1 . Les scores de douleur avant APD etaient a 7,3 ± 1,9 et 7,7 ± 1,9, respectivement pour l’EVA et l’EN. Trente min apres, l’EVA etait a 0,8 ± 1,5 et l’EN a 1,4 ± 1,8. Le CCC (IC95 %) entre l’EVA et l’EN etait a 0,86 (0,73–0,92) et 0,90 (0,82–0,95) respectivement avant et 30 min apres l’APD. Le CCC (IC95 %) entre le % de reduction de la douleur declaree par la patiente et celle calculee pour l’EVA et l’EN etait respectivement de 0,72 (0,51–0,85) et 0,80 (0,63–0,90). Les analyses de BA avant et apres APD sont representees par les Fig. 1 , Fig. 2 . Le biais (limites d’agrement) entre % de reduction de la douleur declaree et celui calcule pour l’EVA et l’EN etait respectivement de −8,9 (34,5) et −3,2 (30). Discussion Cette etude montre une forte correlation entre EVA et EN aussi bien pour les douleurs fortes que pour les douleurs faibles apres APD. Le biais est faible entre l’EVA et l’EN que ce soit avant ou apres APD puisque la difference moyenne est proche de 0 (−0,4 et −0,5) avec une dispersion moins importante pour les douleurs les plus faibles. Les 2 echelles ont une sensibilite a detecter un soulagement moyennement correlee a la reduction de la douleur declaree par les patientes. Neanmoins, l’EN a la meilleure concordance avec le biais le plus faible et la dispersion la moins importante. L’EN permet donc de mieux apprehender l’efficacite analgesique de l’APD. Si ces resultats sont confirmes, cette echelle pourrait etre celle a privilegier pour les etudes cliniques.

Introduction L’enseignement par simulation est une opportunite pour former les etudiants aux gestes techniques difficiles et/ou a risque et ainsi ameliorer la securite des patients [1] . La pose d’une analgesie peridurale (APD) fait partie de ces gestes. Le but de notre etude etait d’apprecier l’impact d’une formation par simulation sur mannequin des internes (DESAR) debutants sur la pose de l’APD en contexte obstetrical. Materiel et methodes Etude observationnelle de type avant–apres dans un centre universitaire avec une maternite de type III, menee sur des DESAR 1 er semestre au tout debut de leur stage. Deux groupes ont ete compares sur 2 periodes : groupe 1 (2010, n = 3) et groupe 2 (2014, n = 5). Les 2 groupes ont recu la 1 re semaine de stage un enseignement theorique sur l’APD. Le groupe 2 a en plus beneficie d’une seance de simulation sur un mannequin rachis adapte a l’apprentissage de l’APD (Lumbar Epidural Injection Trainer - EIT 100 - Pharmabotics Ltd). Sur chacune des periodes, les DESAR beneficiaient d’un compagnonnage par un senior pour les premieres poses d’APD. Le materiel utilise et les protocoles d’analgesie n’ont pas ete modifies entre les 2 periodes. Les parametres recueillis a partir du dossier et de l’interrogatoire des patientes etaient : nombre d’APD posee par un senior dans un 2 nd temps, nombre de ponctions necessaire pour la pose de l’APD, presence de paresthesies a la pose, ponction durale, presence d’une douleur au point de ponction a j1–j2 et son score de douleur evalue par echelle numerique (EN, 0 a 10). Statistique par test de Chi 2 et test- t de Student, significativite pour un p Resultats Soixante-huit poses d’APD ont ete evaluees pour le groupe 1 contre 60 pour le groupe 2. Les resultats figurent dans le Tableau 1 . Les donnees sont exprimees en n (%). Les scores de douleur au point de ponction etaient de 4,8 ± 1,7 et 3 ± 1,7 ( p = 0,001), respectivement pour le groupes 1 et 2. Discussion Associe a un enseignement theorique et a un compagnonnage, l’apprentissage de la pose de l’APD par simulation, de jeunes DESAR, permet d’ameliorer la realisation de ce geste sur certains aspects et ainsi le confort des patientes. Il limite les desagrements comme les paresthesies lors de la pose de l’APD, la frequence et l’intensite des douleurs au point de ponction dans les 1 er jours post-partum. Ces resultats devront etre confirmes sur des series plus importantes d’internes.

Introduction La curarisation residuelle est definie par la presence d’une valeur du train de quatre (TdQ) mesure a l’adducteur du pouce inferieure a 90 %. Elle induit des effets deleteres bien identifies, source d’une majoration de la morbidite et de la mortalite perioperatoire en l’absence d’une antagonisation pharmacologique [1] . Les patients obeses morbides sont une population particulierement a risque de complications respiratoires en cas de curarisation residuelle. Le but de notre etude etait de comparer les performances de 2 moniteurs de la curarisation, l’un necessitant un calibrage, le TOF Watch® et l’autre non calibre le TOF Scan®, pour estimer le niveau de curarisation residuelle chez des patients obeses morbides. Materiel et methodes Etude pilote prospective observationnelle, menee entre janvier et fevrier 2015 dans un centre universitaire. Les patients inclus beneficiaient d’une chirurgie bariatrique (by-pass, sleeve gastrectomie) par voie laparoscopique sous anesthesie generale avec intubation oro-tracheale et curarisation pour l’intubation (succynilcholine ou atracurium) et la chirurgie (atracurium). Les donnees recueillies etaient demographiques, chirurgicales, anesthesiques ainsi que les donnees de la curarisation residuelle. Celle-ci etait evaluee des l’obtention de 4 reponses au TdQ par le rapport T4/T1 affiche. La concordance entre les 2 appareils a ete analysee par le coefficient de concordance de correlation (CCC) et un graphique de Bland et Altman avec limites d’agrement (1,96 X ecart-type [ET]). Resultats Vingt et un patients ont ete inclus dans l’etude. Les caracteristiques de la population sont presentees dans le Tableau 1 . La comparaison des performances des 2 moniteurs pour l’evaluation de la curarisation residuelle a pu etre faite pour 12 patients. Le CCC (95 % IC) des rapports T4/T1 etait de 0,32 (0,12–0,71). La concordance par graphique de BA est presentee dans la Fig. 1 . Le rapport T4/T1 n’etait pas significativement different (biais a -6,25 %) mais avec une large dispersion (limites d’agrement a ± 65,7 %). Discussion Cette etude preliminaire menee sur des patients obeses morbides, montre qu’apres curarisation par atracurium, il existe une mauvaise concordance entre le TOF Watch® et le TOF Scan® pour l’estimation de la curarisation residuelle. Cette variabilite peut influencer de facon plus ou moins appropriee la decision de decurarisation chez cette population a risque. L’absence de biais significatif est en accord avec la litterature dans d’autres contextes [2] . Cependant, l’importance de la dispersion necessite des etudes avec des collectifs plus importants pour valider ce resultat et en determiner les raisons.

Background Dopamine (DA) is released in large amounts during cerebral ischemia and may exacerbate tissue damage. Riluzole (54274 RP) is a recently developed agent that depresses glutamate neurotransmission in the central nervous system (CNS) and that may protect against ischemic injury in some animal models. Because glutamate stimulates the release of DA in the striatum, the authors hypothesized that riluzole could antagonize DA release in this structure. Methods Assay for DA release consisted of superfusing 3H-DA preloaded synaptosomes with artificial cerebrospinal fluid (1 ml/min, 37 degrees C) and measuring the radioactivity obtained from 1-min fractions over 22 min, first in the absence of any treatment (spontaneous release, 8 min), then in the presence of depolarizing agents combined with riluzole (0.1-100 microM, 5 min), and finally with no pharmacologic stimulation (9 min). The following depolarizing agents were tested: KCl (9, 15 mM), veratridine (0.01-1 microM), N-methyl-D-aspartate (NMDA, 0.1-1 mM), kainate (0.1-1 mM), and nicotine (0.01-0.5 mM). Assay for DA uptake was performed by measuring the radioactivity incorporated in synaptosomes incubated with 3H-DA (44 nM; 5 min; 37 degrees C). Results All depolarizing agents produced a significant, concentration-related increase from basal 3H-DA release. Riluzole was found to decrease the release induced by veratridine (1 microM), NMDA (1 mM), and kainate (1 mM) in a significant, concentration-related manner (IC50 = 9.5 microM, 1.6 microM, and 5.8 microM for veratridine, NMDA, and kainate, respectively). In contrast, it did not affect the release elicited by either KCl or nicotine. Riluzole had no significant effect on the specific 3H-DA uptake. Conclusions Riluzole produced a potent blockade of the release of DA mediated by activation of presynaptic sodium channels, NMDA, and kainate receptors. Depression of glutamate transmission together with blockade of DA release may contribute to the actions of this agent in vivo.

Background General anesthetics are thought to produce their hypnotic effects mainly by acting at ligand-gated ionic channels in the central nervous system (CNS). Although it is well established that volatile anesthetics significantly modify the activity of the acetylcholine nicotinic receptors of the neuromuscular junction, little is known about their actions on the acetylcholine receptors in the CNS. In this study, the effects of halothane and isoflurane on the regulation of dopamine (DA) (gamma-aminobutyric acid [GABA]) depolarization-evoked release mediated by nicotinic (muscarinic) presynaptic receptors were studied in the rat striatum. Methods Assay for GABA (dopamine) release consisted of 3H-GABA (3H-DA)-preloaded synaptosomes with artificial cerebrospinal fluid (0.5 ml/min, 37 degrees C) and measuring the radioactivity obtained from 1-min fractions for 18 min, first in the absence of any treatment (spontaneous release, 8 min), then in the presence of depolarizing agents combined with vaporized halothane and isoflurane (0.5-5%, 5 min), and finally with no pharmacologic stimulation (5 min). The depolarizing agents were potassium chloride (KCl; 9 mM) alone or with acetylcholine (10(-6)-10(-4) M) and/or atropine (10(-5) M) for experiments with 3H-GABA, and KC1 (15 mM) and nicotine (10(-7) - 5 x 10(-4) M) alone or with mecamylamine (10(-5) M) for experiments with 3H-DA. Results Potassium chloride induced a significant, Ca(2+)-dependent release of both 3H-GABA and 3H-DA. Nicotine produced a concentration-related, mecamylamine-sensitive 3H-DA release that was significantly attenuated by nicotine (10(-7) M) preincubation. Acetylcholine elicited a dose-dependent, atropine-sensitive reduction of the KC1-evoked 3H-GABA release. Halothane and isoflurane significantly decreased the nicotine-evoked 3H-DA release but had only limited depressant effects on the KC1-stimulated 3H-DA and no action on the KC1-induced 3H-GABA release. The effects of acetylcholine on 3H-GABA release were reversed by halothane but not by isoflurane. Conclusions Clinically relevant concentrations of halothane and isoflurane significantly, but differentially, alter the presynaptic cholinergic regulation of the release of inhibitory neurotransmitters in the striatum. These results suggest that the cholinergic transmission may represent an important and specific presynaptic target for volatile anesthetics in the CNS.

Postpartum hemorrhage (PPH) is defined by loss of greater than 500 mL of blood following vaginal delivery or 1,000 mL of blood following cesarean section, in the first 24 hours postpartum. Its incidence is up to 5% and the severe forms represent 1% of births. PPH is the first cause of obstetrical maternal mortality in France and 90% of these deaths are considered as preventable. Its management is multidisciplinary (obstetricians, anesthetists, midwives, biologists and interventional radiologists), based on treatment protocols where time is a major prognosis factor. In case of failure of the initial measures (oxytocin, manual placenta removal, uterus and birth canal examination), the management of severe forms includes active resuscitation (intravenous fluids, blood transfusion, vasoactive drugs), haemostatic interventions (sulprostone, tamponnade and haemostatic suture, surgical procedures and arterial embolization) and the correction of any potential coagulopathy (administration of blood products and haemostatic agents).

An increase in Mallampati class is associated with difficult laryngoscopy in obstetrics. The goal of our study was to determine the changes in Mallampati class before, during, and after labour, and to identify predictive factors of the changes.Mallampati class was evaluated at four time intervals in 87 pregnant patients: during the 8th month of pregnancy (T(1)), placement of epidural catheter (T(2)), 20 min after delivery (T(3)), and 48 h after delivery (T(4)). Factors such as gestational weight gain, duration of first and second stages of labour, and i.v. fluids administered during labour were evaluated for their predictive value. Mallampati classes 3 and 4 were compared for each time interval. Logistic regression was used to test the association between each factor and Mallampati class evolution.Mallampati class did not change for 37% of patients. The proportion of patients falling into Mallampati classes 3 and 4 at the various times of assessment were: T(1), 10.3%; T(2), 36.8%; T(3), 51.7%; and T(4), 20.7%. The differences in percentages were all significant (P0.01). None of the evaluated factors was predictive.The incidence of Mallampati classes 3 and 4 increases during labour compared with the pre-labour period, and these changes are not fully reversed by 48 h after delivery. This work confirms the absolute necessity of examining the airway before anaesthetic management in obstetric patients.

Urinary retention is a common postoperative complication associated with bladder overdistension and the risk of permanent detrusor damage. The goal of this study was to determine predictive factors of early postoperative urinary retention in the postanesthesia care unit (PACU). We prospectively collected, in 313 adult patients, variables including age, gender, previous history of urinary tract symptoms, type of surgery and anesthesia, intraoperative administration of anticholinergics, amount of intraoperative fluids, IV morphine titration, and bladder volume on entry to the PACU. For each patient, bladder volume was measured by ultrasound on entry and before discharge from the PACU. Urinary retention was defined as a bladder volume larger than 600 mL with an inability to void within 30 min. Predictive factors were identified by multivariate analysis. The incidence of urinary retention in the PACU was 16%. In the multivariate analysis only the amount of intraoperative fluids (or=750 mL; P = 0.02; odds ratio = 2.3), age (or=50 yr; P = 0.008; odds ratio = 2.4), and bladder volume on entry to PACU (or=270 mL; P = 0.0001; odds ratio = 4.8) were found to independently increase the risk of urinary retention. Considering the clinical impact of undiagnosed postoperative urinary retention, these results suggest systematic evaluation of bladder volume with a portable ultrasound device in the PACU, especially in patients with risk factors.In this observational study, the ultrasound monitoring of bladder volume in the postanesthesia care unit (PACU) revealed that postoperative urinary retention occurred with an incidence of 16%. Age (or=50 yr), amount of intraoperative fluid volume (or=750 mL), and bladder volume on entry to PACU (or=270 mL) were independent predictive factors for this complication.

This study examined sex and estrous differences in vocalization thresholds of rats to hindpaw and tail pressure stimulation tested daily throughout at least 3 weeks. When all the measures were pooled, compared to males, female rats had higher thresholds for tail pressure (499 +/- 6 g, n = 188 measures vs. 466 +/- 2 g, n = 144 measures, respectively), but equal thresholds for hindpaw pressure (321 +/- 6 g, n = 188 measures vs. 319 +/- 2 g, n = 144 measures, respectively). Thresholds of female rats in proestrus and estrus were lower than those of rats in metestrus and diestrus for both tail and hindpaw stimulation, whereas those of males did not vary systematically. Thresholds at the two stimulation sites covaried in females but not in males. These results add to the growing list of important interacting factors that underly behavioral sensitivity to noxious somatic stimulation.

To determine the effectiveness of ip bupivacaine and/or morphine for postoperative analgesia after laparoscopic surgery. A controversy exists on the effectiveness and clinical value of ip injection of local anesthetics for postoperative analgesia. A possible peripheral analgesic effect of morphine after ip injection remains debated as well.We conducted a randomized, double-blinded, study to compare the efficacy of prophylactic ip administration of 0.9% saline (n = 16), 0.5% bupivacaine (100 mg, n = 15), morphine (3 mg, n = 16) and a mixture with 0.5% bupivacaine (100 mg) and morphine (3 mg, n = 18) to reduce both postoperative pain scores and analgesic requirements after gynecologic laparoscopic surgery. A multimodal analgesia regimen (acetaminophen, nonsteroidal anti-inflammatory drugs and morphine) was used for postoperative analgesia.No difference was observed in postoperative pain scores (visual analogue scale at rest and on coughing), or analgesic requirements during the first 24 postoperative hours between the four groups. There was also no significant intergroup difference in sedation scores and incidence of nausea and vomiting.When multimodal postoperative analgesia is used, prophylactic ip administration of 100 mg bupivacaine and/or 3 mg morphine does not significantly improve postoperative analgesia in patients undergoing laparoscopic gynecologic surgery.

Background The goal of this study was to evaluate the effectiveness on postoperative pain, and cognitive impact, of patient-controlled analgesia (PCA) compared with subcutaneous (s.c.) injections of morphine in elderly patients undergoing total hip replacement (THR). Methods Forty patients older than 70 yr were randomly assigned to two different postoperative analgesic techniques for 48 h: i.v. PCA morphine (dose, 1 mg; lockout interval, 8 min; PCA group) or regular s.c. morphine injections (SC group). Postoperative pain was assessed at rest and when moving, using a visual analogue scale (VAS) every 4 h. A Mini Mental Status (MMS) examination was used to assess cognitive functions before surgery, at 2 h, 24 h and 48 h after surgery, and at hospital discharge. Side-effects were also recorded systematically during the first 48 h after surgery. Results The PCA group showed significantly lower pain scores than the SC group both at rest and during mobilization. However, the clinical significance of pain scores was weak. There was no intergroup difference in postoperative MMS scores. The incidence of side-effects was similar in both groups. Conclusions We conclude that in healthy elderly subjects undergoing THR, the flexibility of the analgesic regimen is more important than the route of administration with regard to efficacy, adverse effects and recovery of cognitive function.